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Terms and Policy

Notice of Policies and Practices (HIPAA)
Notice of Policies and Practices to Protect the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

- "PHI" refers to information in your health record that could identify you.
- "Treatment, Payment and Health Care Operations"

- Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist.

- Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

- Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

"Use" applies only to activities within my [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

"Disclosure" applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:

- Child Abuse: If I have cause to believe that a child has been, or may be, abused, neglected, or sexually abused, I must make a report of such within 48 hours to the Texas Department of Protective and Regulatory Services, the Texas Youth Commission, or to any local or state law enforcement agency.

- Adult and Domestic Abuse: If I have cause to believe that an elderly or disabled person is in a state of abuse, neglect, or exploitation, I must immediately report such to the Department of Protective and Regulatory Services.

- Health Oversight: If a complaint is filed against me with the State Board of Examiners of Psychologists, they have the authority to subpoena confidential mental health information from me relevant to that complaint.

- Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information, without written authorization from you or your personal or legally appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

- Serious Threat to Health or Safety: If I determine that there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to you, I may disclose relevant confidential mental health information to medical or law enforcement personnel.

- Worker's Compensation: If you file a worker's compensation claim, I may disclose records relating to your diagnosis and treatment to your employer's insurance carrier.

IV. Patient's Rights and Psychologist's Duties
Patient's Rights:
- Right to Request Restrictions -You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.

- Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address.)

- Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.

- Right to Amend - You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.

- Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process.

- Right to a Paper Copy - You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

Psychologist's Duties:
- I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

- I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.

- If I revise my policies and procedures, I will give you a copy of the revised policies in person whenever possible and if not, will mail a copy to your last known address.

V. Complaints

If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me in writing, at the following address: Dr. Vagdevi Meunier, 1004 Mopac Circle, Suite 100, Austin, TX 78746.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I can provide you with the appropriate address upon request.

VI. Effective Date, Restrictions and Changes to Privacy Policy
This notice will go into effect on July 1, 2003 or when you receive a copy of this notice (whichever is sooner).

I will limit the uses or disclosures that I will make as follows:
Limitations:

I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will give you a paper copy of the revised policies whenever possible or send a copy by mail to your last known address.
( Type Full Name )
Office Policies
Vagdevi V Meunier, Psy.D.
Licensed Psychologist
Executive Director for The Center for Relationships, Austin, TX 78759
Phone: 512-330-0355 (for appointments)
________________________________________

COUPLES: Please make sure BOTH of you read and sign off on this informed consent prior to the first session.

Thank you for requesting to begin individual or couples psychotherapy with me. This is a significant decision you have made, both in starting the journey towards growth as well as choosing me as your therapist. In order to make sure you are informed and satisfied with the choice you have made, please read this handout very carefully. Please note that our agreement to work together is voluntary and both/all of us need to agree that I am the best therapist for you.

If you have any questions or concerns about these policies or any other aspect of my practice, please bring it up anytime we meet and I will be happy to clarify aspects of this handout.

PSYCHOLOGICAL SERVICES: Psychotherapy is a significant journey for anyone to embark on. I applaud you for having the courage and insight to recognize that whatever challenges you are dealing with in life right now can be helped with this professional service. If you have never been in therapy before, we will spend some time in the first meeting discussing how I work. Please feel free to bring this up at any time and ask me questions about my background or training and the techniques I use in therapy. My goal is to develop a mutual alliance with you so that we can work together in an open and helpful manner to alleviate your distress or help guide you towards new self awareness.

While my role as a psychologist involves active involvement on my part, I cannot do it without your help. Psychotherapy requires a commitment and investment in this relationship on your part also. Ways you can be helpful and active in the therapy process would be to bring up issues or problems during our meetings especially anything that I may not be aware of; being open to new ideas; and practicing suggestions or new skills that I offer.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Making changes in your beliefs or behaviors can be difficult, and can sometimes be disruptive to the relationships you already have. You may find your relationship with me to be a source of strong feelings. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Most people who take these risks find that therapy is helpful, and I will do what I can to help you minimize risks and maximize positive outcomes. But, there are no guarantees of what you will experience or the outcome.

Our first few sessions will involve an evaluation of your needs and/or relationship. Sometimes I use associates under my supervision to complete this initial structured assessment (with your permission).  You have the right to ask that I be the person conducting the initial assessment.  By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue working with me.  Therapy involves a large commitment of time, money, and energy, so please be very careful about the therapist you select. If you have questions about my procedures, we can discuss them whenever they arise.  I am always happy to recommend or refer you to colleagues I know in the city or in your area so you can explore alternatives or get a second opinion.

After the initial assessment which can take 4-5 sessions or hours, we will discuss my recommendations for counseling and I will make an effort to give you an estimate regarding the duration of counseling.  It is very difficult to accurately predict the length of time it will take to change emotional situations and difficulties but we will collaborate on this decision and try to arrive at a joint agreement.  You have the right to periodically raise this issue with me and discuss progress made so far and how much longer we may need to work together.

You have the right to ask questions about anything that happens in therapy. I am always willing to discuss the rationale for my approaches, and to consider alternatives that might work better. You may feel free to ask me to try something that you think will be helpful. You can ask me about my training for working with your concerns, and you can request that I refer you to someone else if you decide that I am not the right therapist for you. You are free to leave therapy at any time.

INDEPENDENT PRACTICE: I am an independent practitioner and have no professional affiliation with any of the other therapists who practice in offices adjacent to mine.

CONFIDENTIALITY: The privacy and confidentiality of our sessions are extremely important to me. Information about your contact with me and my office will not be disclosed to any person or organization unless you give me a specific, written release to do so. While you are free to discuss anything that occurs in our sessions with anyone, I am required not to discuss such matters without your written authorization. In all aspects of my practice, communication between my clients and me (or between me and those whom my clients have authorized me to contact) are protected by confidentiality regulations as stipulated by federal and state laws, and by professional standards and ethics.

There are, however, some situations written into law that deny me complete control over confidentiality of communication as follows:

1. I am legally required to report any situation of suspected child abuse or neglect to the proper authorities. I am also legally required to report suspected abuse, neglect, or exploitation of an elderly or disabled person.

2. In some circumstances, my records may be subject to a subpoena issued by the court. In particular, confidentiality may be waived with regard to any suit affecting the parent-child relationship.

3. If I believe a client may harm her/himself or another individual, I am permitted by law to break confidentiality by contacting law enforcement officials and/or medical authorities who may then take protective actions.

4. If I am contacted by an insurance company or an auditor, I may be required to release client information as dictated by law. The law also permits me to release information to a collection agency in order to collect on an overdue account.

5. If a client discloses to me the identity of a mental health professional who engaged in sexual contact with him or her during the process of treatment, state law requires me to report that professional to the appropriate district attorney. In this situation, I am not permitted to disclose the identity of the client if he or she does not wish to be identified.

6. Confidentiality does not extend to criminal proceedings in Texas.

This list is not exhaustive, but these are the most common circumstances which may occur. The situations outlined above are out of the ordinary and have no impact on the large majority of people seeking professional mental health services. I share this information with you so that you can be fully informed and your questions and concerns can be addressed.

RECORDS: The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of the records unless I believe that seeing them would be emotionally damaging, in which case I will be happy to send them to a mental health professional of your choice. Clients will be charged an appropriate fee for any time spent in preparing information requests.

FEES: My basic fee is $300 per 45-50-minute individual therapy session, and $300 for a 45-50 minute couples or family therapy session. Longer or shorter sessions are prorated from this basic fee. Fees for psychological testing or reports will be determined on an individual basis and will be discussed with you in advance. Fees for services not covered in this schedule will be agreed upon prior to starting the specific service.

PAYMENT FOR SERVICE: Clients are expected to pay for services at the time they are provided unless other arrangements have been made. Payment may be made by cash, check, or credit card. Clients are responsible for payment of all fees even if planning to bill an insurance company for reimbursement. Any difficulties in payment must be discussed and alternative arrangements made or I may not be able to offer further sessions.

UNPAID ACCOUNTS: If you experience difficulty in meeting your payment obligations, please contact me so we can establish a reasonable payment plan. Overdue accounts (i.e., which remain unpaid for 90 days or for which an agreed-upon payment plan has not been followed) may be turned over to a collection agency as a final resort for non-payment. Overdue accounts may also be subject to interest charges and collection fees.

INSURANCE REIMBURSEMENT: In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for therapy. If you have a health insurance policy, it may provide some coverage for mental health treatment. I will provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out what costs are covered by your insurance and that we agree on the terms by which you will seek reimbursement for your psychotherapy costs through your insurance company. Since I am not a pre-certified provider on your insurance plan, I will be asking you to pay me in full and seek reimbursement from your insurance company. I will be happy to assist you in this process as needed.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. "Managed Health Care" plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. Some plans may require you to receive treatment from a therapist who is on their provider panel. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person's usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end.

You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer or in a cloud database. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with other insurance, life insurance, or governmental entities or make the information part of a national database that can be used to determine future benefits to you.  I value helping my clients make informed decisions that protect their freedom and privacy so please let me know if I can assist you with any research or information.

CANCELLATIONS: A minimum of 24 hours notice is required for rescheduling or cancellation of an appointment. The full fee will be charged for missed sessions without such notification. Please note that many insurance companies will not provide payment for missed sessions.

LEAVING MESSAGES: You are welcome to call me and leave a message at (512) 330-0355. If it is an emergency please do not just leave me a message as I may not get it in a timely fashion. Please read the next item for further resources you can use in the community if you are in urgent need.

DIGITAL CONSENT: Federal and State regulations govern the communication, storage, and dissemination of private health information that is stored on or communicated through digital media. Please review the separate digital consent form carefully.

EMERGENCIES: To the extent possible, I will regularly check my voicemail messages and return calls as soon as possible. If I am out of town, I will make arrangements with a colleague to provide coverage on my behalf. In case you are not able to reach me as soon as you would like to, here are some numbers you can call:

24-hour Crisis Hotline 472-4357
Shoal Creek Psychiatric Hospital 452-0361
St. David's Pavilion Psychiatric Hospital 867-5800
Brackenridge Hospital 476-6461
General Emergency Number 911


Digital Consent Form

Due to changing regulations regarding the dissemination of digital communication as found in the nationwide HIPAA Omnibus rule, effective September, 2013 and Texas law H.B.300, it is necessary for us to have a clear agreement regarding the use of digital communication. PHI (Protected Health Information) pertains to all patient health information that is protected by law. Digital PHI is held to the same confidentiality standards as hard copy documents.

Outlined below are my policies regarding the use of digital communication in my psychology practice:

Email
Standard email providers such as Yahoo, Gmail, AOL, Outlook, Hotmail etc. do not provide the required level of privacy protection required to communicate regarding Private health information (PHI). As such, I discourage the use of the above, or any other generic email provider, to communicate with me regarding any sensitive personal health information. You may send an email to vagdevi@thecenter4relationships.com with your name, contact information, and a request for an appointment or callback, but please do not discuss private health information via emails. If you need to communicate with me via email, I encourage the use of the following free email services which do conform to the HIPAA standard for PHI communication. These are: Hushmail (www.hushmail.com) and Counsol, the mail service provided through the website: (https://drvagdevi.secureclientarea.com).

Phone
Phone technology, which includes talk, text, and voicemail, is a ubiquitous form of communication. However it is not secure, and as such, I recommend that you use it judiciously when it comes to discussing PHI. With voicemails, I recommend that you leave a message with your name and contact information only. You may leave a request for an appointment and information regarding a preferred method or time of contact, but please do not discuss details of PHI in your voicemail. Conversely, when I (or my professional assistant) contact you via phone or voicemail, we will refrain from discussing PHI.

Website
Dr. Meunier's secure client website is hosted by Counsol, a website provider which follows HIPAA compliance security measures to safeguard all data. Through this private website (https://drvagdevi.secureclientarea.com) you may securely book an appointment, pay a bill, or send a message to Dr. Meunier. You are welcome to ask that your information not be stored on this website. Please be aware that if you have an account on the website, you can opt to receive text and email reminders of your appointments or opt out of that service.

Payments
You may pay a bill through cash or check in-session or via credit card through Counsol (https://drvagdevi.secureclientarea.com) or paypal (www.paypal.com). Although we cannot guarantee total security, as these are 3rd party websites, credit card information is used only to settle immediate balances. When you store a credit card on Counsol.com, it is managed by Stripe which is a secure credit card processing service. Please let me know if you have any objections or concerns about the use of these 3rd party services. You are always welcome to pay for your sessions in cash or by check.

Social Media
I do not accept personal friend requests or communicate with any current, former, or potential clients through any social networking site whether it be Facebook, LinkedIn, Instagram, Twitter or any other method of online social interaction. Current, former, or potential clients are invited to "like" or "follow" any company or professional page that Dr. Vagdevi Meunier may establish, but no personal communication will be accepted through a social networking website as it is impossible to protect PHI via these methods.

I have read and understand the above privacy policies and practices and agree to comply with them in all my communications with Dr. Vagdevi Meunier


OFFICE POLICIES CONSENT SIGNATURES

By signing below, you (and your partner) are attesting the following:

I/We have read and understood Dr. Meunier's privacy practices notice as required by HIPAA, digital informed consent form and Dr. Meunier's office policies. I/We understand I/we may request a paper copy at our first meeting for my records.

I/We have read, understand, and agree to the contents of all the documents listed above. We are entering into a voluntary psychotherapy service contract with Vagdevi Meunier, Psy.D. which may include counseling, testing, or diagnostic evaluation. We understand that therapy is a joint effort between the psychologist and client, the results of which cannot be guaranteed.

I/We understand that this agreement is voluntary and that we can end therapy at any time and can request a referral to another therapist if I am/we are not willing or able to follow the recommendations of my therapist.

I/We have agreed that the payment per hour will be $300. Payment is non-refundable once service has been provided.

I/We agree that I/we will be responsible for the payment of all professional fees at the time of service unless prior arrangements have been made. In case of couples therapy, both parties are individually and jointly responsible for any unpaid invoices.

Couples and Family Therapy: We understand that therapy records are maintained as one record and that any point after today, both of the adults' signatures will be required to release any information regarding this service.

If you are in agreement with this office policies document, please sign BOTH OF your names below. You are agreeing that this electronic signature will suffice as evidence of your consent and I do not need a hand-written signature to begin providing professional services to you.

IMPORTANT: PLEASE NOTE:
If you are seeing me as a couple, please make sure your partner/spouse has read this document as well and please sign BOTH of your names below to show that you are both consenting to this service.
( Type Full Name )